Highlights and Lowlights from Monte
Plata 2019
Changes
This was a good year.
It was also a different year.
This year our team went to Monte Plata as we had done before in January
of 2019 but this year we planned and did our project as a one week
project. Now on the surface, it would
seem as if that is not a really big deal. We still had to recruit, supply and
to execute in the same manner. It seemed
that recruiting went easier in asking people to commit for only one week. In the past the commitment has been one with
options. They could come for two weeks,
one week or part of both. It made it
difficult for me because of having to make sure we had the people in the
critical positions covered for the whole time.
For example, if all of the anesthesia personnel wanted the first week
then the surgeons on the seconds week couldn’t have as many tables to
work. If all surgeons wanted the second
week then the anesthesia from the first week had no cases to do. In most years, I don’t have the team
completed until December with sometimes filling in the last slot in early
January. This year with only one week to
choose from, we filled the team to capacity in late September. There is a capacity for the camp where we
stay and we filled that number and with the right mix of participants in the
critical slots.
For the most part the supply side is a little easier except
for the medications. We collect
disposable supplies year round and sterilize them in October prior to the
trip. I estimate how many cases we may
do based on prior years experience and on the personnel that we have signed
up. So 1 or 2 weeks just requires
different estimations and then collecting the supplies. God provides all the time, but we sometimes
have to work harder. We must order
medications for the clinic and medications for anesthesia in advance, so the
estimates differ in amount depending on numbers that we estimate.
This year we had 42 participants with us and
each was able to take a 27 gallon plastic tub with supplies. Since the airlines limits the weight to 50
pounds for each tub (or suitcase), that gave us a capacity of 2,100 pounds of
supplies. Realistically we probably had
around 1600 pounds when we were all packed.
There was a concern with changing to one week we would be
sacrificing the reach of the project. As
it turned out we did as many surgeries as last year in two weeks. This was by having 3 OR tables running for
the 5 days of the week instead of 2 tables for 8 days. The clinic was clearly busier each day of the
week with more patients seen daily but only going to 5 locations instead of the
8 last year.
There was a more concerted
effort on the ground in the DR prior to our arrival to advertise and spread the
word of our coming this year with radio ads as well as the truck with a loud
speaker going thru the towns to announce our arrival. (I’m fairly sure that
technique would not go over well here in the States announcing the arrival of a
new doctor in town.) We chose the towns
to visit based on last year’s turn out so as to maximize our impact and, it
seemed to work.
The Team
We returned to the same “camp” for housing. We have stayed in a compound that is
surrounded by an 8 foot cinder wall. It
contains the Eva Russell School that was built by the local church who sponsors
us in the town.
It was almost new when
we first started coming to Monte Plata in 2003.
It has changed over the years with a few new buildings and expansions
and growth of the plants and trees. One
of the upgrades this year was converting two of the shower bathrooms downstairs
near the classrooms to bathrooms with multiple stools. That is great for the kids but for our team
of 42 it was a little problem especially when one of the remaining 4 showers
broke (think gushing water and broken pipes).
That left 2 baths and showers upstairs for the 26 girls and 1 shower and
2 baths downstairs for the 16 guys. Not
quite the standards for a 4 star resort.
We had 13 first timers with us this year and our returning
participants had logged 1 -19 previous trips besides myself. They came from South Dakota, Des Moines Iowa,
Chattanooga Tennessee, Kansas City, Jackson and Jefferson City Missouri. The remainder of the group came from Wichita,
Winfield and Arlington Kansas. It is
always interesting to hear the stories of the group when we begin to get to
know each other. Everyone comes for
different reason and at different seasons of their life. We had participants born in the 40’s, 50’s,
60’s 70’s 80’s and 90’s.
We also had 2
young people born in the 2000’s. But
even with the age range differences, we all enjoyed each other and learned from
each other.
Medical and Dental Clinic
We have been blessed with a stable crew of providers to staff
our clinic over the years and it paid dividends this year with the shortened
schedule. Our first clinic day was for
the people of Monte Plata. We stayed in
the camp since it was a holiday for the school.
It helps to allow the clinic team to do their first day in the camp to
develop processes and procedures that allow them to then take the show on the
road so to speak. They then traveled to
El Cacique, Don Juan Chirino and Kilometer 12 to provide clinic services to the
rural areas surrounding the Monte Plata area.
Our total patients seen between clinic, eye, dental and surgery were
actually 10 more that seen in the previous year on a 2 week project. Our three pharmacists (a rare bonus to have
three) were able to dispense 2439 prescriptions to those we saw.
Their cases always seem to have something new and different
every year. This year a man walked into
the clinic with a leg wound that had been present for months. When he pulled his pants leg up we saw a
lower leg with no skin left in place and a non healing wound. It the US the only option for him would be an
amputation since the wound could not heal without months of intensive therapy
and possibly skin grafting. We were left
but to clean up the wound and dress it properly. We frequently take for granted the facilities
and technology we have in the states.
Most were seen and given prescriptions for their most acute need along
with vitamins and parasite treatments.
Some were referred to the hospital clinic for us to see and some had
surgery that week others that were referred were then sent to the capital if we
were unable to care for them in our surgery clinic.
Our dentist worked under very primitive conditions and was
able to provide a full range of dental services to 109 patients. Everything from cleaning, to filling to
sealants and extractions were done in a portable chair in our open are clinic
with a gasoline generator to power the dental equipment. Eye exams were done on 315 patients and 157
of them received glasses.
Surgical Services
We continue to work with our colleagues in the Hospital
Provincial de Monte Plata. Some of the
staff there has been in Monte Plata since before we came and it is always great
to see them and be greeted by the enthusiasm of the patients. Each morning as we arrived to the large lobby
area we were greeted by applause from the patients. We then would sing “Alabare” and start our
day with a corporate prayer. The
hospital works hard to improve the health of the people in Monte Plata and has
initiated a campaign to encourage all their staff to reach out to the patients
and ask “How may I help you”. They had
buttons made for each of our team and presented them to us with our name on the
button to make us feel at home and part of them.
With our team consolidated to one week, we were able to have
three operating tables work at the same time.
It did present some problems from a space standpoint. Last year with two tables in one OR and one
preop room and one post op room we were all close by each other. This year with more volume we needed two post
op and two preop rooms. That meant that
we were spread over a larger area on the second floor of the hospital. The hospital normally doesn’t use the second
floor for patients, just surgery and labor and delivery with the nursery. We had to use walkie talkies to be able to
communicate between rooms and to staff to keep the flow of patients.
Most of our patient has their surgery done as an outpatient
going home the same day. The larger surgeries like gall bladder
surgery or hysterectomies stay overnight and go home the next morning.
That means that we have to transfer the
patients to the service of the hospital for overnight care. The hospital medical director has worked with
us at least 3-4 years and she assumes the care during the night. We return the next morning and see the
patients and dismiss them. The hospital
does have an elevator but it broke twice while we were there. Once while trying to bring the heavy anesthesia
machines up to the OR. The second time
was late in the day on Wednesday. We
were all tired and the last patient was ready to go downstairs to her bed. All of the staff was done except for post op
crew. They were the last finished most
days due to the nature of their area. As
they were waiting for the elevator it broke (think trapped between
floors). The prior time with the
machines and two of our transport crew a short wait was endured before the
hospital opened the door with the key to the elevator. This time after waiting and trying to figure
out what to do with our patient (do we carry her down the winding stairs?) the
hospital maintenance staff arrived. They
went on the roof and did something and returned to the second floor and opened
the outer door with the key and yelled up the shaft in Spanish “lower, lower,
lower” until the elevator was visible and the inner door was opened. They then motioned for us to push the cart
and patient onto the elevator. After a
short delay of people looking at each other, we pushed the cart and patient
into the elevator. (Did I mention that
there was not one of those stickers in the elevator telling when it was last
certified?) The maintenance person then
closed the outer door and ran down the stairs to the bottom and opened the
outer door with the magic key and yelled again in Spanish “lower, lower, lower”
until the elevator appeared slowly from above.
Then, he yelled “stop, stop”. We
pictured someone on the room lowering the rope attached to the elevator hand
over hand until it was in just the right position with beads of sweat on his
forehead. He then opened the inner door
to the huge smiles of the staff that pushed the cart out and down the hall as
if nothing happened.
I am occasionally asked what kind of cases you not want do
while you are there. This year I tracked
the cases and found them to fall in 5 categories. The first has to do with coexisting illnesses
that make surgery too risky. While it
might not be too risky here in the States, in the DR on project we just don’t
have the back up in either technology or personnel. This would be like patients with uncontrolled
high blood pressure or blood sugars. The
second category is for conditions that are too complex. Cases of obvious cancers that are extensive
can’t be adequately staged or treated there in a Provincial Hospital. I saw a 19 year old with a large mass under
his chin that pushed his tongue up. We
don’t have CT scans or many diagnostic studies to define the problem. The third group involves patients that have
conditions that require specialist in areas that are not present on our
team. We had many patients that desired
surgery for urologic conditions and we didn’t have a urologist with us, nor the
equipment that they use. One of the broadest
groups is for patients that we can’t operate on are those that have pain that
is not related to a surgical problem.
When patients know we are coming they show up with symptoms but don’t
know if surgery will help their condition but rely on us to tell them if we can
help. Frequently those patients are
relieved and reassured that they don’t need surgery. We had advertised that we would take care of
hernias. One patient came in to have his
hernia fixed but it was a herniated disc in his back that he had and it’s not
something that we could or should do surgery.
One patient that we saw was an American who was in the DR
with another ministry drilling water wells for the villages. He fell off a ladder and landed on his
arm. It caused quite an abrasion. After 4 days the pain and swelling had not
gone down. He saw one member of our
group at a local ice cream shop one evening and was excited to see American
doctors.
He came to the surgery clinic
the next day and we were able to get an x-ray of his arm to find no
fracture. Our clinic provided the
antibiotic and wound care he needed to get him thru his project and returned to
Michigan for follow up.
The last category of people who don’t get surgery are those
who have conditions where surgery is contraindicated such as for keloid
scars. These can be unsightly but the
repair is almost always associated with re-occurrences of the scars that are
worse than the first. We strive to above
all do no harm with our surgeries.
An unusual case this year was a young man who was in a
motorcycle accident that resulted in him being thrown from the cycle and
fracturing his femur and tibia.
The
femur was repaired with a plate place in surgery and a device called an
external fixator for the tibia fracture.
That in and of itself was not unusual but it happened 3 years ago and
the fixator is usually removed after 6-8 weeks of healing. For some unknown reason (think financial) he
was sent home with the tools to remove the fixator but the patient never
followed up with anyone. He saw one of
our translators a month ago and when he heard we were coming he asked if we
could help. Pictures of the leg and
device were sent to me over WhatsApp and I showed it to our surgeons who showed
it to orthopedics surgeons.
They said we
could and should remove the hardware as the risk of osteomyelitis (bone
infection) was very high as long as it stayed in place. We took some special instruments from the
States with us and saw the young man and said we could help. He was ecstatic having been limited in his
activities for over 3 years from the device.
With sedation, a 7 minute procedure was done to remove the device and he
went home all smiles, well mostly smiles.
We sometimes examine patients and end up referring the patient to specialists in the Capital city. Some follow up and go; others don’t for a number of reasons.
Progress
Sometimes it seems as if nothing changes. It almost was like stepping into a time
chamber for us and we return and seem to pick up where we were last year. This year a couple of things changed. The ministry works largely because of the
permanent staff in the Dominican Republic.
They do all the leg work to make sure we can do what we do with the
government blessings. They also maintain
all the hard assets necessary for doing the short term projects. That includes trucks, buses, cars as well as
all the OR tables, lights anesthesia machines and supplies that we bring in
excess of need. Several projects are
unable to bring anything with them and the extras are what they run their
project with. This year I was pleased to
be able to tour the newly constructed warehouse. It was made of 3 shipping containers in a “U”
shape with a metal 2 story building over the top.
It is in a secure area with some land around
it. It is quite an improvement for the
ministry and the staff to have.
The second area was in personal growth and development of the
staff. One of the interpreters that I
have worked with for 10 years will begin the final year of medical school in the
DR in March along with a second person a year later. Another supply manager last year has left the
ministry to start his own foundation in Sabana Grande de Boya to help the youth
of his home town. It is so easy to get
excited and want to come back to a place where there is such a giving and
caring environment.
Conclusion
I think that the point is that there is not a conclusion to
helping others. The need continues and
by addressing that need we all can find meaning in our lives. So while we may know we are home by being reminded
with the blistering cold winds and snow, we know we will step back in time to
the DR in a few months to the warmth of not only the weather but the
friendships we have made and cherish.
